Green Paper needs open discussion

The South African Department of Health has clearly made significant gains in certain areas of the health system. However, analysis presents a picture of an underperforming system in almost every area. South Africa spends as much, and in some cases more, on health care than its peer countries. Yet it is experiencing poorer health outcomes and a rise in the burden of major diseases, according to a report by the Helen Suzman Foundation. The report has been submitted to to the department in response to the recently published National Health Insurance Green Paper (NHIGP).

Although acknowledging many of the problems in the health system, the NHIGP fails to provide evidence-based links between poor health outcomes and their causes. The paper cites the two-tiered health system and inequalities between the public and the private sectors as the root causes of the majority of South Africa’s poor health outcomes. While these factors may undermine an attempt at creating equality in society, this proposition fails to take into account the systemic, institutional problems evident in both the public and the private health systems.

The problems in the public health system include: lack of governance and accountability, ineffective monitoring and evaluation, poor management, over-centralisation, lack of implementation of existing policies, and corruption. The issues resulting in rising costs and inefficiencies faced by the private sector include: market imperfections, a lack of price competition and lack of effective regulation. Whether or not these issues can be resolved by the introduction of a NHI scheme remains unclear.

Review of the NHIGP

The Foundation finds that the NHIGP is characterised by statements and claims which are not supported by evidence or appropriate references. It also lacks much of the detail required to provide a more engaged response to the policy proposals.

A primary concern is that the apparent lack of a comprehensive, evidence-based plan could result in further deterioration of the health system. It is imperative that clear and reliable evidence is provided to demonstrate that the policy proposals of the Green Paper will improve the ability of South Africans to access health care.

Constitutional and human-rights implications
Section 2 of the Constitution reaffirms that the Constitution is the supreme law of the republic and that law or conduct inconsistent with it is invalid and that the obligations imposed by it must be fulfilled. Thus, every citizen and every arm of government ought  to be concerned about constitutionalism and its preservation.

The Department of Health needs to show that the policy proposals outlined in the NHIGP will positively assist the state in the progressive realisation of the right to access healthcare enshrined in Section 27 of the Constitution.

Similarly, the Department of Health needs to ensure that the NHIGP proposals are in accordance with the Constitution. A particular area of concern is the potential for the undermining of the constitutional rights and decision-making powers of the provinces.

The importance of public consultation
Public participation and consultation on the proposed NHI still has a long way to go. Historical and international evidence of creating and implementing healthcare reform suggests that it is a complex process requiring an equal measure of open debate in the policy-making process and resource capacity in the implementation stage.

The Department of Health appears to have presented an already defined proposal drafted with minimal public and stakeholder consultation. As a result, the Foundation sees the NHIGP rather as the first step towards health reform, with space reserved for further consultative development of the detail and scope for creative thought.

The goal of universal coverage

Universal coverage in healthcare can be described as a system whereby all citizens have access to quality healthcare when needed and are not exposed to ruinous financial risk when accessing it.

It could be argued that South Africa already provides universal coverage by virtue of the current two-tiered health system: On the one hand, the tax-funded public system provides coverage to those who are unable to afford private healthcare. On the other hand, formally employed individuals and those able to afford it, are covered by the private health sector via contributions to medical schemes.

The problem is thus rather one of access and quality than lack of coverage.

The key question then is: what are the most important and critical steps to take in working towards improving access to quality healthcare and what are the most relevant policy mechanisms for achieving them?

The importance of management
Appropriate management across all levels of the health system is crucial for the successful reform of the system. The introduction of the NHIGP provides an opportunity to finally and emphatically correct malfunctioning management structures and practices in the health sector.

Health management needs to be clearly distinguished from administration. It should be decentralised, and must take a long-term view. Managers must be trained and granted the opportunity to make decisions in respect of the areas of the healthcare system that have been entrusted to them.

Conclusion
The Helen Suzman Foundation is positive that the correct reforms to the healthcare system can be decided on and implemented. It is vital however, that reforms are discussed and debated in a transparent manner, with broad-based consultation and sober acknowledgement of the real challenges facing the healthcare system.

“We trust that this is the start of an open discussion on the best way to move forward to ensure improvement in access to quality healthcare for all South Africans.”

(The full submission can be downloaded here)